The Effect of VCO (Virgin Coconut Oil) Therapy for Skin Moisture

in Chronic Kidney Client

Pitriani

, Wira Maria Ginting

, Samuel Ginting

, Anita Purba

, Arfah Maysara

Faculty of Nursing and Physiotherapy, Institut Kesehatan Medistra Lubuk Pakam, Sumatera Utara, Indonesia

Faculty of Public Health, Institut Kesehatan Medistra Lubuk Pakam, Sumatera Utara, Indonesia

Keywords: VCO (Virgin Coconut Oil), Skin moisture, Chronic Kidney

Abstract: Chronic Kidney Failure Patients who undergo hemodialysis (HD) have complex problems such as dry skin

that often triggers itching, itching is experienced by patients with chronic renal failure results in a disturbance

in skin moisture. VCO (Virgin Coconut Oil) is pure coconut oil which is used to treat complaints of itching

and dry skin experienced by clients. The purpose of this research to determine the effect of VCO (Virgin

Coconut Oil) therapy on skin moisture in clients with Chronic Kidney Failure with Hemodialysis at RS Grand

Mark Lubuk Pakam. The design of this research is Quasi experimental, Design with non equivalent pretest-

posttest control group design, using control group and intervention group. The sample consisted of 52

respondents, consisting of 26 respondents as an intervention group who was given VCO therapy and 26

respondents as a control group. The statistical test used was the Dependent T test and the Independent T test.

The results showed that there was a significant influence between the control group and the intervention group

before and after the intervention (P Value = 0,000). The results of this study can be used as an alternative

therapy for clients experiencing skin dryness using VCO (Virgin Coconut Oil), especially in clients with

chronic kidney failure with hemodialysis.

1 INTRODUCTION

Chronic Kidney Disease (CKD) is a chronic disease

that progressively damages the kidneys and disrupts

the balance of fluids and body electrolytes that affect

the whole systems. (Hasneli, 2017). World Health

Organization (WHO) released data on growth for the

number of people with chronic kidney failure in the

world in 2013 increased by 50% from the previous

year and in America the incidence of chronic kidney

failure increased by 50% in 2014 and every year

200.000 Americans undergo hemodialysis. The

incidence of kidney failure in the world globally is

more than 500 million people and those who have to

undergo hemodialis around 1.5 million people

(Yuliana, 2015). It is estimated that the number of

CKD sufferers in Indonesia is around 70,000 people

and those undergoing hemodialysis are 10,000 people

(Tandi, Mongan, & Manoppo, 2014 in Hasneli,

2017).

In one third of CKD patients complain of

symptoms of lack of energy (76%), pruritus (74%),

drowsiness (65%), dyspnea (61%), edema (58%),

pain (53%), dry mouth (50%) , muscle cramps (50%),

lack of appetite (47%), poor concentration (44%), dry

skin (42%), sleep disturbance (41%), and

constipation (35%). (Aisara, 2018).

Uremic pruritus is a common complication and

affects the quality of life of patients with Terminal

Chronic Kidney Failure undergoing Hemodialysis

(HD). Uremic pruritus is most often described as a

daily or almost daily itching event that stretches

bilateral symmetrical surface area. Uremic pruritus

can vary from general itching that attacks the back,

face and arms. (Daryaswanti, 2018).

Uremic pruritus has no specific etiology, but

several factors that cause pruritus are mentioned such

as dry skin, reduced transidermal elimination of

pruritogenic factors, hyperparathyroidism, increased

histamine levels, increased mast cell proliferation in

the skin and increased levels of calcium, magnesium

and high phosphate. Non-pharmacological

interventions that have been studied can reduce

uremic pruritus, including the provision of

acupuncture (Kim, Lee, Choi, & Ernst, 2010) and the

provision of Virgin Coconut Oil (VCO) (Melastuti

2016).

Pitriani, ., Maria Ginting, W., Ginting, S., Purba, A. and Maysara, A.

The Effect of Virgin Coconut Oil Therapy for Skin Moisture in Chronic Kidney Client.

DOI: 10.5220/0010019306110617

In Proceedings of the International Conference on Health Informatics and Medical Application Technology (ICHIMAT 2019), pages 611-617

ISBN: 978-989-758-460-2

611

Dry skin that appears in patients with chronic

renal failure with hemodialysis is usually caused by

atrophy of the sebaceous glands, impaired function of

external secretions, and impaired hydration of the

stratum corneum. Dry skin in patients with

hemodialysis who have pruritus has lower hydration

than hemodialysis patients without pruritus

complaints (Roswati, 2013).

Dry skin in pruritus is caused by vitamin A

retention due to reduced kidney function to excrete

substances that are not needed by the body. So that

Vitamin A will accumulate in subcutaneous tissue.

Too much vitamin will cause atrophy of the

sebaceous glands and sweat glands so that the skin

becomes dry and itchy.

Virgin Coconut Oil (VCO) is pure coconut oil

produced from the processing of coconut meat

without heating or through heating at low

temperatures so as to produce oil with a clear color

and free of free radicals due to heating (Handayani et

al, 2011). The content of fatty acids (especially lauric

and oleic acids) in VCO has character that can soften

the skin. VCO is effectively used as a moisturizer on

the skin so it can increase skin hydration and

accelerate healing of the skin (Agero & Verallo-

Rowell, 2004; Lucida et al, 2008 in Rukmana, 2017).

Virgin coconut oil (VCO) also contains natural

moisturizers and contains moderate chain saturated

fatty acids that easily enter the inner skin layers and

maintain skin elasticity and suppleness. Lauric acid

and capric acid contained in virgin coconut oil can kill

viruses. In the body, lauric acid is converted into

monocaprin; these compounds include

monoglyceride compounds that are antiviral,

antibacterial, antibiotic and antiprotozo. (Meliyana,

2017). Giving of virgin coconut oil (VCO) aims to

prevent injury to the skin due to friction from the

massage action. Pure coconut oil has antiseptic

effects and is used as an efficient and safe skin

moisturizer (Debmandal & Mandal, 2011).

2 RESEARCH METHODS

This research was conducted at Grandmed Hospital,

located at Jl Raya Medan, No.66, Lubuk Pakam. The

research was conducted in February - July 2019. This

type of research is a quasi-experimental design with

pre-test and post-test two groups. The research

sample consisted of 25 people and was divided into 2

groups: group I was given VCO (Virgin Coconat Oil)

intervention and Group II was not given VCO

intervention but only given a questionnaire with a

sample size of 25 people each, with an estimated drop

out of 10% (3 people), then a sample of 27 people in

the intervention group and 27 in the control group.

When doing research in the course of research in the

intervention group died 1 person and in the control

group also died 1 person so that the total sample is

now 26 for the intervention group and 26 control

groups.

Figure 1: Research groove

In this research, the type of research that used is

quasi experimental Design with a non equivalent

Pretest-Posttest control group design. The population

in the study was all clients of chronic kidney failure

with hemodialysis in the hemodialysis room at the

Grand Medistra Hospital in Lubuk Pakam in

February-July 2019 totaling 198 people. The sample

in this study was taken by purposive sampling

technique. In this study, the total sample of the study

was 52 people with 26 respondents in the control

group and 26 respondents in the intervention group.

The instrument which used was a tool to measure

skin moisture (SK-IV Digital Moisture for Skin

Monitor). Inclusion criteria in this study are: (1)

Patients undergoing regular hemodialysis twice a

week, (2) Patients have dry skin with a value of 0-

35%. The drop out criteria in this research is: (1)

Patients die before a post test, (2) Patients who resign

during the implementation of the intervention.

Scores that is used to calculate skin moisture from

a scale (SK-IV Digital Moisture for Skin Monitor) are

dry skin 0-35%, normal skin 36-45%, moist skin that

is 46-100%.

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

612

The procedures for taking Virgin Coconut Oil

(VCO) intervention are

 Introduce ourself and explain the purpose of

the Virgin Coconut Oil (VCO) intervention.

 Giving informed consent before taking

action.

 Giving SK-IV questioners to the

intervention and control groups on the first

day pre-test

 The patient was asked to free the skin which

will be examined for skin moisture meter

from the clothes worn.

 Instruct the patient in a comfortable position

 Put the skin moisture meter on the skin for 6

seconds

 To keep patient’s privacy

 Giving of VCO in the intervention group as

many as 14x (1 mgg) in the morning and

evening as much as 5 cc for each

intervention.

 The time that is needed to intervene in the

provision of VCO is 20 minutes.

 10. After completing the intervention, help

to use the clothes worn before.

2.1 Virgin Coconat Oil (VCO)

Virgin coconut oil is pure coconut oil that is made

without heating or with minimal heating. The using

of virgin coconut oil as a skin and hair care ingredient

has been carried out by Indonesian people for

generations. Coconut is a fruit plant that is widely

available in Indonesia and is generally used as a food

ingredient in the form of processed fresh coconut

meat or made oil for cooking and caring for the body.

Processed oil from coconut meat consists of 2 types,

namely oil which is processed from copra raw

material (dried coconut meat) and oil which is

processed from raw materials of fresh coconut or

coconut milk. Processing of raw materials of fresh

coconut produces virgin coconut oil.

How to make VCO: with a mechanical process, in

this method, coconut meat is dried quickly and then

pressed until the oil comes out. In this way 90% oil

and 10% water will be obtained. The water separated

from the oil is separated while the water contained in

the oil is heated quickly to evaporate.

Figure 2: round coconut

Figure 3: cut the coconut into small pieces

Figure 4: squeeze the coconut

Figure 5: distill coconut milk

The Effect of Virgin Coconut Oil Therapy for Skin Moisture in Chronic Kidney Client

613

Figure 6: pure coconut oil

2.2 Skin Moisture

Skin moisture is a state of moisture in the stratum

corneum and a balance between evaporation of water

and the ability of the skin to retain water. Skin that

has decreased moisture can cause cracks, allowing

germs that can cause infections into the body. Skin

hydration and mucous membranes help uncover the

imbalance of body fluids, changes in the skin

environment, and regulation of body temperature.

Skin moisture level can be measured using

digital devices which are currently widely used in the

beauty and health fields. Skin Moisture Meter FCM1

has the special ability to measure skin's moisture

level. In the skin analyzer, has an LCD screen that

serves to display data on the measurement of skin

moisture. This tool has a design and shape that is

small and portable so that it can be carried anywhere.

Skin moisture measurement is done in a very short

time, that is, within 6 seconds and appears as a

percentage figure.

Standard values of moisture to the skin on the arm are:

0-35%: very dry skin, 36-45%: normal skin, 46-

100%: moist skin.

Figure 7: Skin Moisture Tool

3 RESULTS AND DISCUSSION

3.1 Characteristics of Respondents

Distribution of respondent data based on the age of

the majority aged 30-45 years in the intervention

group amounted to 14 people or 53.8%, while the age

of respondents in the control group 46-55 years

amounted to 11 people or 42.3%, which is the

productive age, where the pattern changes Eat and

consume frequent supplement drinks often at this age.

Whereas respondents based on sex in the majority

of the intervention group were male, 14 people or

53.8%, and in the majority control group there were

22 people or 84.6%, and in the education group for

the intervention group of primary education and

education middle school is in the number of 11 people

or 42.3%, while in the control group secondary

education is in the number of 11 people or 42.3%. In

the work of the majority of respondents working as

traders in the intervention group as many as 7 people

or 26.9%, and in the work control group others as

many as 6 people or 23.1% ie respondents who do not

work cannot continue their previous work due to

health conditions decreased, while the duration of HD

0-5 years in the intervention group was 16 people or

61.5% and in the control group the duration of HD 0-

5 years was 23 people or 88.5%. It was caused by

habits in consuming foods that contain gout and low

habits in consuming drinking water.

Table 1: Characteristics of Respondents

Information

Intervention

group

Control group

n % n %

Age (years)

30-45 14 53,8 % 6 23,1%

46-55

56-65

23,1%

42,3%

43,6%

Total 26 100% 26 100%

Gender

Laki-laki 14 53,8% 22 84,6 %

Perempuan 12 46,2% 4 15,4%

Total 26 100% 26 100%

Education

No education 1 3,8%

- -

Primary

education

11 42,3% 10 38,4%

Secondary

education

11 42,3% 11 42,3%

Higher

education

3 11,5% 5 11,5%

Total 26 100% 100%

Occupation

No 5 19,2% 5 19,2%

Housewife 5 19,2% 2 7,7%

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

614

Farmer 3 11,5% 4 15,4%

Trader 7 26,9% 1 3,8%

Teacher 2 7,7% 2 7,7%

Enterpriser 2 7,7% 5 19,2%

Police 1 3,8% - -

Civil servant - - 1 3,8%

Etc. 1 3,8% 6 23,1%

Total 26 100% 16 100%

Length

HD(Tahun)

0-5 16 61,5% 23 88,5%

6-10 8 30,8% 3 11,5%

>10 2 7,7% - -

Total 26 100% 26 100%

3.2 The Results of Wilcoxon TEST

(Prepost Test) of Skin Moisture in

Treatment and Control Groups at

RS Grandmed Lubricant

Table 2. The test of Wilcoxon (pre-post test) of skin

moisture for treatment and control groups at RSGrandMed

Lubricant

Skin Moisture

Pretest Posttest P

value

Mean +_SD Mean +_

Interventi

on group

20,31+-4,84 41,08+-

5,95

0,000

Control

group

21,96+-5,89 21,12+-

4,44

0,557

The data above shows that there is an increase in

the mean value in the intervention group after giving

the intervention (post test), which is the mean value ±

SD (41.08 ± 5.95), while the control group shows a

decrease in the mean post test value (21.12 ± 4.44) .

An increase in the mean value in this treatment group

showed an increase in skin moisture in chronic renal

failure patients undergoing hemodialysis. Wilcoxon

test results showed a significant value in the treatment

group (p = 0,000).

3.3 The Effect of VCO Giving on CKF

Patients' Skin Moisture

VCO has been done for one week shows significance

which means that there is an effect of giving VCO to

skin moisture in patients with CRF. This research is

in accordance with the results of the study

(Evangelista, Casintah, & Villafuerte, 2014) which

mentioned the superior effect of VCO that topically

applied oils not only coat but also penetrate the skin

and have anti-inflammatory activity. VCO has

saturated fat and contains 62% of medium chain fatty

acids which may give greater permease. The results

of the research (Sukarja, 2016) the administration of

cutaneous stimulation and VCO resulted in fatty acids

binding to sweat and then coating the surface of the

skin so that it can hold water in the stratum corneum

so that the skin becomes moist.

In patients undergoing hemodialysis due to

chronic renal failure, various skin lesions will appear,

and the most common being dry skin. In 100

hemodialysis patients, 79% of patients experience dry

skin (Ankudowicz, 2016). Chronic Kidney Failure

can cause changes in the sweat glands and oil glands

which causes the skin to lose its natural ability to

moisturize itself. This condition can also be caused by

changes in metabolism in CKF, which are interrelated

with fluid volume from patients undergoing dialysis

(Perry, Anne Griffin, Potter, Patricia A., Stockert,

Patricia A., Hall, 2013).

Virgin Coconut Oil (VCO) is coconut oil obtained

from fresh coconut meat through natural processes,

without bleaching, without purification and

deodorizing. The main component of VCO is medium

chain fatty acids, especially about 50% lauric acid.

Unlike traditional coconut oil, the process of making

VCO does not use high temperature heating so that

free radicals do not form unsaturated fatty acids and

the natural antioxidant content is not lost. VCO

applied to the skin will affect body tissues, especially

connective tissue, making the skin moist.

Skin moisture pre-test values in the treatment

group and control group of all patients were at a very

dry level (100%). Post-test results in the control

group, all patients are still at a very dry level, this is

because in this group did not get. Some of the usual

interventions performed by patients in the control

group in dealing with dry skin is by bathing using

baby soap or using lotion.

Whereas in the treatment group after being given

a VCO intervention for one week, 11 people (42.3%)

had normal skin, 9 people (34.6%) had moist skin,

and 6 (23%) skin was still very dry. Although 6

people in the treatment group were still at very dry

skin level, but when viewed from the raw value, there

was an increase in the value of the six people. As

many as 17 people after being given an intervention

have not been at the level of the skin becomes moist.

As many as 11 people who were previously on the

level of dry skin to normal skin, there is an increase

in value of approximately 20 points. While as many

as 6 people remain in dry skin conditions even though

there is an increase in value in quantity. This is

because the skin moisture value during the pre test is

at a very low value (<21%), so to reach the normal

The Effect of Virgin Coconut Oil Therapy for Skin Moisture in Chronic Kidney Client

615

value requires a considerable increase in points.

Increasing the value of the six people is

approximately 15 points. Skin conditions in each

patient are certainly not always the same, several

factors that cause these patients are still in the

condition of dry skin after one week of intervention

due to atrophy of the sebaceous glands associated

with decreased lipid surface that causes dehydration

of the stratum corneum (Masmoudi 2014). In

addition, the length of time a patient undergoes HD

can also influence, due to the decrease in sweat glands

along with the abnormal function associated with

hypervitaminosis A when the patient undergoes

dialysis (Ankudowikcz, 2018; Mendez, 2015).

It varies in post-test humidity values that appeared

in the intervention group did not affect itching in

patients. Moisture level of the skin is very dry, normal

and moist after one week of intervention, giving the

effect of reducing itching on the patient's skin. It

shows VCO intervention given can reduce the itching

experienced by patients even though the patient's skin

is still at a very dry level. The reduction in itching felt

by the patient is caused by VCO administration.

According to Evangelista's research (2014), VCO can

reduce score in Atopic Dermatitis patients, VCO can

also moisturize the skin and reduce pruritus scores

without giving antihistamines. Pruritus resolution can

be explained by concomitant improvement in barrier

function on the skin. Disorders of the skin barrier alter

epidermal innervation and increase nerve density in

the skin.

4 CONCLUSION

Based on the results of the statistical tests and the

discussion above, it can be concluded that Giving of

VCO intervention increases skin moisture in patients

with chronic renal failure in theGrandMed Lubuk

Pakam Hospital. Through the main components of

VCO are Medium Chain Fatty Acids (MCFAs)

especially about 50% lauric acid when applied to the

skin with a soft and uniform touch, will bind to sweat

and coat the surface of the skin by holding water in

the stratum corneum.

5 SUGGESTION

For hospitals in general, it is hoped that VCO

interventions can be complementary therapies to help

overcome the problem of dry, itchy skin in other

patients except for patients with CKF.

For the next researchers, it is hoped that further

research can be measured by measuring ureum

creatinine after being given a VCO intervention on

the itching experienced by the patient or measuring

the endogeneous morphine level of the patient related

to comfort after being given a VCO intervention.

REFERENCES

Alligood, M.R., 2014. Nursing Theorist and Their Work

Eighth Edit, United State of America: Elsevier.

Amin, S. 2009. Cocopreneurship Aneka Peluang Bisnis dari

Kelapa. Jogjakarta: Lily Publisher.

Ankudowicz, A. (2016). Do Patients With End-Stage

Chronic Renal Failure Treated With the and Basic

Education About Risk Factors for Skin Cancer in This.

Transplantation Proceedings, 48, 1435–1438.

https://doi.org/10.1016/j.transproceed.2016.03.004

Ankudowicz, A., Krol, Ewa., Slizien, Alicja Debska.,

Czemych, Radoslaw. (2018). The Risk of Skin Disease

in Maintenance Hemodialysis. Transplantation

Proceedings.

https://doi.org/10.1016/j.transproceed.2018.02.133.

Asmadi. (2008). Teknik Prosedural Keperawatan: Konsep

dan Aplikasi Kebutuhan Dasar Klien. Jakarta: Salemba

Medika.

Brunner & Suddarth. (2002). Buku Ajar Keperawatan

Medikal Bedah. Jakarta: EGC.

Bulechek, G. M., Butcher, Howard K., Dochterman, Joanne

M., Wagner, Cheryl.(Ed.). (2013). Nursing

Interventions Classification (NIC) (Sixth Edit). United:

Elsevier Mosby.

Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R.,

& Kupfer, D. J. (1989). The Pittsburgh Sleep Quality

Index : A New Instrument Psychiatric Practice and

Research. Psychiatry Research, 28, 193–219.

Dahlan, Muhamad Sopiyudin. (2011). Statistik untuk

Kedokteran dan Kesehatan: Deskriptif, Bivariat dan

Multivariat, Dilengkapi Aplikasi dengan Menggunakan

SPSS, Edisi 5, Salemba Medika, Jakarta.

Debmandal, M., & Mandal, S. (2011). Coconut ( Cocos

nucifera L .: Arecaceae ): In health promotion and

disease prevention. Asian Pacific Journal of Tropical

Medicine, 4(3), 241–247.

https://doi.org/10.1016/S1995-7645(11)60078-3

Dharia, Sushma M., Brown, Lee K., Unruh, Mark L.

(2015). 'Sleep and Sleep Disorder in Chronic Kidney

Disease' dalam P. Kimmel & M. Rosenberg (Eds.),

Chronic Renal DiseaseI, Elsevier Inc, hal. 332-349

Egger-rainer, A., Trinka, E., Hö, J., & Maria, A. (2017).

Epilepsy & Behavior Epilepsy monitoring –The

patients â€TM views A qualitative study based on

Kolcaba â€TM s Comfort Theory. Epilepsy &

Behavior, 68, 208–215.

https://doi.org/10.1016/j.yebeh.2016.11.005.

Evangelista, M., Casintahan, F., & Villafuerte, L. (2014).

The effect of topical virgin coconut oil on scorad,

transepidermal water loss and skin capacitance in mild

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

616

to moderate pediatric atopic dermatitis: A randomized,

double-blind clinical trial. International Journal of

Dermatology, 53(4), 100–108.

https://doi.org/10.1111/ijd.12339

Hidayat, A. (2006). Pengantar Kebutuhan Dasar Manusia:

Aplikasi Konsep dan Proses Keperawatan. Jakarta:

Salemba Medika

Hollis, M. (1998). Massage for Therapists (2nd Editio).

United Kingdom: Blackwell Science.

Hou, Y., Hu, P., & Liang, Y. (2014). Effects of Cognitive

Behavioral Therapy on Insomnia of Maintenance

Hemodialysis Patients. Cell Biochemistry Biophysics,

69, 531–537. https://doi.org/10.1007/s12013-014-

9828-4

Kim, K. H., Lee, M. S., Choi, S. M., & Ernst, E. (2010).

Acupuncture for treating uremic pruritus in patients

with end-stage renal disease: A systematic review.

Journal of Pain and Symptom Management, 40(1),

117–125.

https://doi.org/10.1016/j.jpainsymman.2009.11.325

Kolla, P. K., Desai, M., Pathapati, R. M., Mastan Valli, B.,

Pentyala, S., Madhusudhan Reddy, G., & Vijaya

Mohan Rao, A. (2012). Cutaneous Manifestations in

Patients with Chronic Kidney Disease on Maintenance

Hemodialysis. ISRN Dermatology, 2012, 1–4.

https://doi.org/10.5402/2012/679619

Krinsky, R., Murillo, I., & Johnson, J. (2014). A practical

application of Katharine Kolcaba â€TM s comfort

theory to cardiac patients. Applied Nursing Research,

27(2), 147–150.

https://doi.org/10.1016/j.apnr.2014.02.004

Lemeshow, Stanley., Hosmer, David W., Klar, Janelle.,

Lwanga, Stephen K. (1991). Adequacy of Sample Size

in Health Studies. John Wiley & Sons: New York.

Liaveri, P. G., Dikeos, D., Ilias, I., Lygkoni, E. P., Boletis,

I. N., Skalioti, C., & Paparrigopoulos, T. (2017).

Quality of sleep in renal transplant recipients and

patients on hemodialysis. Journal of Psychosomatic

Research, 93, 96–101.

https://doi.org/10.1016/j.jpsychores.2016.12.013

Masmoudi, A., Darouiche, M. H., Salah, H. Ben, Hmida,

M. Ben, & Turki, H.(2014). Cutaneous Abnormalities

in Patients with End Stage Renal Failure on Chronic

Hemodialysis. A Study Of 458 Patients. J Dermatol,

86–94.

Melastuti, Erna & Setyaningrum, D. A. (2016).

Effectiveness of providing Virgin Coconut Oil (VCO)

towards pruritus reduction: Study on patients with

chronic kidney disease undergoing hemodialysis. The

Proceeding of the 7th International Nursing Conference

Faculty of Nursing Universitas Airlangga, 281–285.

Mendez, J.C Robles., Martinez, O. Vazques., Candiani. J.

Ocampo. (2015). Skin Manifestations of Chronic

Kidney Disease. Actas Dermosifiliograficas, 106(8),

609-622.

The Effect of Virgin Coconut Oil Therapy for Skin Moisture in Chronic Kidney Client

617